http:// Thu, 14 Jan 2010 20:33:38 GMT Thu, 14 Jan 2010 20:33:38 GMT modmedadmin@advanstar.com (ModernMedicine) modmedadmin@advanstar.com (ModernMedicine) KickApps Feed Builder 2010-01-14T20:33:38Z 19 http://community.modernmedicine.com/service/searchEverything.kickAction?as=33379&includeBlog=on&sortType=recent 93789 http://community.modernmedicine.com/_A-Look-into-the-Future-of-Monitoring-Neurological-Disability-with-the-Proposed-new-Healthcare-System/BLOG/1716418/33379.html In a recent article (abstract) on health-related quality of life in MS (MS), the authors evaluate the utilities which are identified as a "key summary index measure" of increasing neurologic disability reflective of different stages of MS.1 Their specific focus was on the relapsing-remitting and secondary progressive forms of MS, with disability measured by the Expanded Disability Status Scale (EDSS). It is important to point out that, clinically, MS can have a very benign course with or without immunomodulating therapy in a significant number of patients. However, a not insignificant proportion experience a progressive disabling course. This has a primary economic effect on the patient and family in terms of work status and support system costs. The health care system is affected by the relatively expensive medications along with physical and occupational therapy as well as functional aides, and so on. MS would appear, from my perspective, to be an ideal neurologic disorder to use as a model for a cost-benefit analysis. The type of information gathered in studies such as that by Naci et al can provide an objective determination of how effectively medical and economic goals are being met with presently available treatment regimens for chronic neurologic disability secondary to disorders such as MS. Although such data collection is not necessarily as exciting as an article about a new treatment for MS, in the grand scheme of the proposed new health care system in the United States, reining in healthcare costs will be pivotal. Thus, specific attention to outcome measures, including quality of life issues, would appear to become increasingly important to justify what specific treatment regimens will be covered by this proposed health care plan. Hopefully, there will be greater efficiencies that will not only help to control healthcare costs but also allow greater support to improve outcomes. Reference Naci H, Fleurence R, Birt J, et al. The impact of increasing neurological disability of MS on health studies: a systematic review of the literature. J Med Econ. Posted online on Jan 4, 2010. In a recent article (abstract) on health-related quality of life in MS (MS), the authors evaluate the utilities which are identified as a "key summary index measure" of increasing neurologic disability reflective of different stages of MS.1 Their specific focus was on the relapsing-remitting and secondary progressive forms of MS, with disability measured by the Expanded Disability Status Scale (EDSS). It is important to point out that, clinically, MS can have a very benign course with or without immunomodulating therapy in a significant number of patients. However, a not insignificant proportion experience a progressive disabling course. This has a primary economic effect on the patient and family in terms of work status and support system costs. The health care system is affected by the relatively expensive medications along with physical and occupational therapy as well as functional aides, and so on. MS would appear, from my perspective, to be an ideal neurologic disorder to use as a model for a cost-benefit analysis. The type of information gathered in studies such as that by Naci et al can provide an objective determination of how effectively medical and economic goals are being met with presently available treatment regimens for chronic neurologic disability secondary to disorders such as MS. Although such data collection is not necessarily as exciting as an article about a new treatment for MS, in the grand scheme of the proposed new health care system in the United States, reining in healthcare costs will be pivotal. Thus, specific attention to outcome measures, including quality of life issues, would appear to become increasingly important to justify what specific treatment regimens will be covered by this proposed health care plan. Hopefully, there will be greater efficiencies that will not only help to control healthcare costs but also allow greater support to improve outcomes. Reference Naci H, Fleurence R, Birt J, et al. The impact of increasing neurological disability of MS on health studies: a systematic review of the literature. J Med Econ. Posted online on Jan 4, 2010. Thu, 14 Jan 2010 20:33:38 GMT http://community.modernmedicine.com/_A-Look-into-the-Future-of-Monitoring-Neurological-Disability-with-the-Proposed-new-Healthcare-System/BLOG/1716418/33379.html rkelley 2010-01-14T20:33:38Z Neurology Modern Medicine Community In a recent article (abstract) on health-related quality of life in MS (MS), the authors evaluate the utilities which are identified as a "key summary index measure" of increasing neurologic disability reflective of different stages of MS.1 Their specific focus was on the relapsing-remitting and secondary progressive forms of MS, with disability measured by the Expanded Disability Status Scale (EDSS). It is important to point out that, clinically, MS can have a very benign course with or without immunomodulating therapy in a significant number of patients. However, a not insignificant proportion experience a progressive disabling course. This has a primary economic effect on the patient and family in terms of work status and support system costs. The health care system is affected by the relatively expensive medications along with physical and occupational therapy as well as functional aides, and so on. MS would appear, from my perspective, to be an ideal neurologic disorder to use as a model for a cost-benefit analysis. The type of information gathered in studies such as that by Naci et al can provide an objective determination of how effectively medical and economic goals are being met with presently available treatment regimens for chronic neurologic disability secondary to disorders such as MS. Although such data collection is not necessarily as exciting as an article about a new treatment for MS, in the grand scheme of the proposed new health care system in the United States, reining in healthcare costs will be pivotal. Thus, specific attention to outcome measures, including quality of life issues, would appear to become increasingly important to justify what specific treatment regimens will be covered by this proposed health care plan. Hopefully, there will be greater efficiencies that will not only help to control healthcare costs but also allow greater support to improve outcomes. Reference Naci H, Fleurence R, Birt J, et al. The impact of increasing neurological disability of MS on health studies: a systematic review of the literature. J Med Econ. Posted online on Jan 4, 2010. cost-benefit analysis, health care reform, multiple sclerosis, neurology nonadult false A Look into the Future of Monitoring Neurological Disability with the Proposed new Healthcare System text blog cost-benefit analysis,health care reform,multiple sclerosis,neurology 10 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771761&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1413325_33379_2771761_ap_160X120.jpg false 0 0 1716418 2771761 Member 0 http://community.modernmedicine.com/_The-Condition-Termed-Mild-Cognitive-Impairment/BLOG/1621330/33379.html There has been increasing interest in the term mild cognitive impairment (MCI) to identify a potential precursor to Alzheimer’s disease (AD). There is a nice review on this topic in the December issue of Archives of Neurology with Ronald C. Peterson, MD, as the lead author.1 The authors note that the term MCI was coined in 1988 to identify mild level of severity in dementia rating scales for very early dementia. This reminds me of the use of the term benign forgetfulness of senescence, which was used in the past to reassure the family that their elderly loved one was just demonstrating the not-unexpected mild memory disturbance associated with advanced age. MCI has gained increasing popularity because it can be used to distinguish forgetfulness that is more of a nuisance (forgetting where the car keys are) from that which is a clinically significant memory disturbance (forgetting where one is going when driving and getting lost in a potentially dangerous area). Thus, the level of severity is important to recognize as is the potential for rather selective involvement of various cognitive realms in dementing illness. A person may retain faculties that allow reasonably safe independent living even with moderate dementia. On the other hand, loss of effective judgment and impulse control can, along with the associated memory disturbance, make the situation much more worrisome from a safety standpoint. Peterson and colleagues point out that there are various forms of MCI and not all forms evolve into AD. They also state that the recognition of MCI is very important for identifying individuals who are at risk for AD, providing the potential for intervention. Although there is little that can be offered presently, it is hoped that interventions to protect against progression to AD will be available in the not-too-distant future. In pursuit of this, the concept of MCI has fostered imaging research examining avenues such as serial volumetric measurements of brain tissue to monitor and predict the progression from MCI to AD. Such imaging information will provide an objective surrogate marker of potential response to new therapy in addition to clinical response assessed by serial cognitive batteries. [Editor’s Note: Do you have any thoughts about this topic? Login and Comment in the box below.] Reference 1. Peterson RC, Roberts RO, Knopman DS, et al. Mild cognitive impairment: ten years later. Arch Neurol. 2009;66(12):1447-1455. There has been increasing interest in the term mild cognitive impairment (MCI) to identify a potential precursor to Alzheimer’s disease (AD). There is a nice review on this topic in the December issue of Archives of Neurology with Ronald C. Peterson, MD, as the lead author.1 The authors note that the term MCI was coined in 1988 to identify mild level of severity in dementia rating scales for very early dementia. This reminds me of the use of the term benign forgetfulness of senescence, which was used in the past to reassure the family that their elderly loved one was just demonstrating the not-unexpected mild memory disturbance associated with advanced age. MCI has gained increasing popularity because it can be used to distinguish forgetfulness that is more of a nuisance (forgetting where the car keys are) from that which is a clinically significant memory disturbance (forgetting where one is going when driving and getting lost in a potentially dangerous area). Thus, the level of severity is important to recognize as is the potential for rather selective involvement of various cognitive realms in dementing illness. A person may retain faculties that allow reasonably safe independent living even with moderate dementia. On the other hand, loss of effective judgment and impulse control can, along with the associated memory disturbance, make the situation much more worrisome from a safety standpoint. Peterson and colleagues point out that there are various forms of MCI and not all forms evolve into AD. They also state that the recognition of MCI is very important for identifying individuals who are at risk for AD, providing the potential for intervention. Although there is little that can be offered presently, it is hoped that interventions to protect against progression to AD will be available in the not-too-distant future. In pursuit of this, the concept of MCI has fostered imaging research examining avenues such as serial volumetric measurements of brain tissue to monitor and predict the progression from MCI to AD. Such imaging information will provide an objective surrogate marker of potential response to new therapy in addition to clinical response assessed by serial cognitive batteries. [Editor’s Note: Do you have any thoughts about this topic? Login and Comment in the box below.] Reference 1. Peterson RC, Roberts RO, Knopman DS, et al. Mild cognitive impairment: ten years later. Arch Neurol. 2009;66(12):1447-1455. Fri, 18 Dec 2009 18:02:52 GMT http://community.modernmedicine.com/_The-Condition-Termed-Mild-Cognitive-Impairment/BLOG/1621330/33379.html rkelley 2009-12-18T18:02:52Z Neurology Modern Medicine Community There has been increasing interest in the term mild cognitive impairment (MCI) to identify a potential precursor to Alzheimer’s disease (AD). There is a nice review on this topic in the December issue of Archives of Neurology with Ronald C. Peterson, MD, as the lead author.1 The authors note that the term MCI was coined in 1988 to identify mild level of severity in dementia rating scales for very early dementia. This reminds me of the use of the term benign forgetfulness of senescence, which was used in the past to reassure the family that their elderly loved one was just demonstrating the not-unexpected mild memory disturbance associated with advanced age. MCI has gained increasing popularity because it can be used to distinguish forgetfulness that is more of a nuisance (forgetting where the car keys are) from that which is a clinically significant memory disturbance (forgetting where one is going when driving and getting lost in a potentially dangerous area). Thus, the level of severity is important to recognize as is the potential for rather selective involvement of various cognitive realms in dementing illness. A person may retain faculties that allow reasonably safe independent living even with moderate dementia. On the other hand, loss of effective judgment and impulse control can, along with the associated memory disturbance, make the situation much more worrisome from a safety standpoint. Peterson and colleagues point out that there are various forms of MCI and not all forms evolve into AD. They also state that the recognition of MCI is very important for identifying individuals who are at risk for AD, providing the potential for intervention. Although there is little that can be offered presently, it is hoped that interventions to protect against progression to AD will be available in the not-too-distant future. In pursuit of this, the concept of MCI has fostered imaging research examining avenues such as serial volumetric measurements of brain tissue to monitor and predict the progression from MCI to AD. Such imaging information will provide an objective surrogate marker of potential response to new therapy in addition to clinical response assessed by serial cognitive batteries. [Editor’s Note: Do you have any thoughts about this topic? Login and Comment in the box below.] Reference 1. Peterson RC, Roberts RO, Knopman DS, et al. Mild cognitive impairment: ten years later. Arch Neurol. 2009;66(12):1447-1455. cognitive impairment, forgetfulness, neurology nonadult false The Condition Termed “Mild Cognitive Impairment” text blog cognitive impairment,forgetfulness,neurology 180 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771761&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1413325_33379_2771761_ap_160X120.jpg false 1 0 1621330 2771761 Member 0 http://community.modernmedicine.com/_Neuroenhancements-Ethical-to-give-to-the-healthy-adult/BLOG/1530776/33379.html There is a provocative article in the journal Neurology on neuroenhancements for adult patients.1 This topic will surely generate some discussion and debate as it deals with the prescribing of medications to neurologically normal patients to augment or enhance their normal cognitive or affective function. The article states that although this needs to be done via a traditional physician-patient relationship which addresses the ethical and legal responsibilities to the patient, such a prescription is not ethically or legally obligatory or prohibited. In fact, in the proper context, the Ethics, Law and Humanities Committee views such an action as “ethically permissible.” Naturally, as part of the evaluation, one must factor in the risks versus the benefits of such an approach, and there is the right of refusal. The authors write that “the principles of informed consent apply to the use of medications for neuroenhancement,” but do not specify what type of informed consent is required. Use of a consent form that is approved by the local Human Subjects Committee or the local Risk Management office is implied, however. It appears that the most practical approach is to have thorough discussion with the patient and any significant others that might be present. And this be documented carefully in the records before such a practice is initiated and not after. However, in my perspective, neuroenhancement is not necessarily out of the realm of everyday practice in neurology. A number of our patients, as they get older, become forgetful and might well benefit from a cholinesterase inhibitor for what could be mild cognitive impairment (MCI) before it evolves into clinically significant Alzheimer’s disease. Giving stimulants to patients who fall asleep easily, especially when they are taking medications that promote sleepiness, may help prevent accidents, including motor vehicle accidents, and make the roads safer for the patient and for others. It is not all uncommon to have a patient “lose focus” and become distracted over personal issues. Although not necessarily true depression, job performance and interpersonal relationships can be affected. Such a situational process might well respond to the relatively safe antidepressants now available. Thus, there are probably relative contributing factors to the patient seeing the need for “neuroenhancement” from their physician perhaps somewhat akin to requesting ED agents for another part of the body. Reference 1. Larriviere D, Williams MA, Rizzo M, et al; on behalf of the AAN Ethics, Law and Humanities Committee Responding to requests from adult patients for neuroenhancements. Guidance of the Ethics, Law and Humanities Committee. Neurology. 2009;73:1406-1412. doi:10.1212/WNL.0b013e3181beecfe There is a provocative article in the journal Neurology on neuroenhancements for adult patients.1 This topic will surely generate some discussion and debate as it deals with the prescribing of medications to neurologically normal patients to augment or enhance their normal cognitive or affective function. The article states that although this needs to be done via a traditional physician-patient relationship which addresses the ethical and legal responsibilities to the patient, such a prescription is not ethically or legally obligatory or prohibited. In fact, in the proper context, the Ethics, Law and Humanities Committee views such an action as “ethically permissible.” Naturally, as part of the evaluation, one must factor in the risks versus the benefits of such an approach, and there is the right of refusal. The authors write that “the principles of informed consent apply to the use of medications for neuroenhancement,” but do not specify what type of informed consent is required. Use of a consent form that is approved by the local Human Subjects Committee or the local Risk Management office is implied, however. It appears that the most practical approach is to have thorough discussion with the patient and any significant others that might be present. And this be documented carefully in the records before such a practice is initiated and not after. However, in my perspective, neuroenhancement is not necessarily out of the realm of everyday practice in neurology. A number of our patients, as they get older, become forgetful and might well benefit from a cholinesterase inhibitor for what could be mild cognitive impairment (MCI) before it evolves into clinically significant Alzheimer’s disease. Giving stimulants to patients who fall asleep easily, especially when they are taking medications that promote sleepiness, may help prevent accidents, including motor vehicle accidents, and make the roads safer for the patient and for others. It is not all uncommon to have a patient “lose focus” and become distracted over personal issues. Although not necessarily true depression, job performance and interpersonal relationships can be affected. Such a situational process might well respond to the relatively safe antidepressants now available. Thus, there are probably relative contributing factors to the patient seeing the need for “neuroenhancement” from their physician perhaps somewhat akin to requesting ED agents for another part of the body. Reference 1. Larriviere D, Williams MA, Rizzo M, et al; on behalf of the AAN Ethics, Law and Humanities Committee Responding to requests from adult patients for neuroenhancements. Guidance of the Ethics, Law and Humanities Committee. Neurology. 2009;73:1406-1412. doi:10.1212/WNL.0b013e3181beecfe Mon, 30 Nov 2009 20:06:11 GMT http://community.modernmedicine.com/_Neuroenhancements-Ethical-to-give-to-the-healthy-adult/BLOG/1530776/33379.html rkelley 2009-11-30T20:06:11Z Neurology Modern Medicine Community There is a provocative article in the journal Neurology on neuroenhancements for adult patients.1 This topic will surely generate some discussion and debate as it deals with the prescribing of medications to neurologically normal patients to augment or enhance their normal cognitive or affective function. The article states that although this needs to be done via a traditional physician-patient relationship which addresses the ethical and legal responsibilities to the patient, such a prescription is not ethically or legally obligatory or prohibited. In fact, in the proper context, the Ethics, Law and Humanities Committee views such an action as “ethically permissible.” Naturally, as part of the evaluation, one must factor in the risks versus the benefits of such an approach, and there is the right of refusal. The authors write that “the principles of informed consent apply to the use of medications for neuroenhancement,” but do not specify what type of informed consent is required. Use of a consent form that is approved by the local Human Subjects Committee or the local Risk Management office is implied, however. It appears that the most practical approach is to have thorough discussion with the patient and any significant others that might be present. And this be documented carefully in the records before such a practice is initiated and not after. However, in my perspective, neuroenhancement is not necessarily out of the realm of everyday practice in neurology. A number of our patients, as they get older, become forgetful and might well benefit from a cholinesterase inhibitor for what could be mild cognitive impairment (MCI) before it evolves into clinically significant Alzheimer’s disease. Giving stimulants to patients who fall asleep easily, especially when they are taking medications that promote sleepiness, may help prevent accidents, including motor vehicle accidents, and make the roads safer for the patient and for others. It is not all uncommon to have a patient “lose focus” and become distracted over personal issues. Although not necessarily true depression, job performance and interpersonal relationships can be affected. Such a situational process might well respond to the relatively safe antidepressants now available. Thus, there are probably relative contributing factors to the patient seeing the need for “neuroenhancement” from their physician perhaps somewhat akin to requesting ED agents for another part of the body. Reference 1. Larriviere D, Williams MA, Rizzo M, et al; on behalf of the AAN Ethics, Law and Humanities Committee Responding to requests from adult patients for neuroenhancements. Guidance of the Ethics, Law and Humanities Committee. Neurology. 2009;73:1406-1412. doi:10.1212/WNL.0b013e3181beecfe doctor-patient relationship, medical ethics, neurology nonadult false Neuroenhancements: Ethical to give to the healthy adult? text blog doctor-patient relationship,medical ethics,neurology 194 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771761&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1413325_33379_2771761_ap_160X120.jpg false 0 0 1530776 2771761 Member 0 http://community.modernmedicine.com/_Amyotrophic-Lateral-Sclerosis-Update-from-the-Quality-Standards-Subcommittee-of-the-American-Academy-of-Neurology/BLOG/1479655/33379.html The various manifestations of what is termed “motor neuron disease” are primarily lower motor neuron involvement, primarily upper motor neuron involvement, primarily progressive bulbar paresis, or most commonly, the combination of upper motor neuron (long tract signs with spastic weakness and hyperreflexia) and lower motor neuron signs (atrophic weakness with fasciculations) often referred to as amyotrophic lateral sclerosis (ALS). The involvement of the bulbar musculature heralds a worse prognosis in terms of swallowing and speech difficulty as well as respiratory involvement. The diagnosis must be established with as much certainty as possible and involves not only a detailed history and thorough neurologic exam but also an electomyogram with nerve conduction velocities. This neurophysiologic study is vitally important and often requires considerable expertise. If there’s any question about the diagnosis, refer to a center with particular expertise in motor neuron disease because the implications of the diagnosis include death, often within several years from onset. However, this can very much depend on the manifestations and the level of supportive care warranted and requested. It is very important not to “give up” on the patient; monitoring the neurologic condition over time can provide considerable emotional support for both the patient and the family. The recent evidence-based review from the American Academy of Neurology (AAN) recommends considering riluzole to slow the disease progression, percutaneous endoscopic gastrostomy (PEG) to stabilize the patient’s weight and to prolong survival, and noninvasive ventilation (NIV) to treat respiratory insufficiency in an effort to prolong survival.1 In an accompanying article, the authors recommend referral to a multidisciplinary clinic should also be considered to improve the quality of life and to ensure that an extra effort is being made to address what can be considerable management needs. Refractory sialorrhea may respond to boxulinum toxin B or low-dose radiation to the salivary glands. Dextromethorphan and quinidine may prove helpful for pseudobulbar affect if approved by the FDA. The authors point out that the excessive fatigue which can be associated with use of riluzole, if counterproductive for the patient, should lead to consideration of its discontinuation. The authors also point out the importance of monitoring for cognitive and behavioral manifestations, including dementia. Despite the limited therapeutic options presently available for ALS, supportive measures and patients’ access to them must be kept in mind for this often devastating neurologic disorder.2 References 1. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review). Neurology. 2009;73:1218-1226.2. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review). Neurology. 2009;73:1227-1233. The various manifestations of what is termed “motor neuron disease” are primarily lower motor neuron involvement, primarily upper motor neuron involvement, primarily progressive bulbar paresis, or most commonly, the combination of upper motor neuron (long tract signs with spastic weakness and hyperreflexia) and lower motor neuron signs (atrophic weakness with fasciculations) often referred to as amyotrophic lateral sclerosis (ALS). The involvement of the bulbar musculature heralds a worse prognosis in terms of swallowing and speech difficulty as well as respiratory involvement. The diagnosis must be established with as much certainty as possible and involves not only a detailed history and thorough neurologic exam but also an electomyogram with nerve conduction velocities. This neurophysiologic study is vitally important and often requires considerable expertise. If there’s any question about the diagnosis, refer to a center with particular expertise in motor neuron disease because the implications of the diagnosis include death, often within several years from onset. However, this can very much depend on the manifestations and the level of supportive care warranted and requested. It is very important not to “give up” on the patient; monitoring the neurologic condition over time can provide considerable emotional support for both the patient and the family. The recent evidence-based review from the American Academy of Neurology (AAN) recommends considering riluzole to slow the disease progression, percutaneous endoscopic gastrostomy (PEG) to stabilize the patient’s weight and to prolong survival, and noninvasive ventilation (NIV) to treat respiratory insufficiency in an effort to prolong survival.1 In an accompanying article, the authors recommend referral to a multidisciplinary clinic should also be considered to improve the quality of life and to ensure that an extra effort is being made to address what can be considerable management needs. Refractory sialorrhea may respond to boxulinum toxin B or low-dose radiation to the salivary glands. Dextromethorphan and quinidine may prove helpful for pseudobulbar affect if approved by the FDA. The authors point out that the excessive fatigue which can be associated with use of riluzole, if counterproductive for the patient, should lead to consideration of its discontinuation. The authors also point out the importance of monitoring for cognitive and behavioral manifestations, including dementia. Despite the limited therapeutic options presently available for ALS, supportive measures and patients’ access to them must be kept in mind for this often devastating neurologic disorder.2 References 1. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review). Neurology. 2009;73:1218-1226.2. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review). Neurology. 2009;73:1227-1233. Mon, 09 Nov 2009 21:05:22 GMT http://community.modernmedicine.com/_Amyotrophic-Lateral-Sclerosis-Update-from-the-Quality-Standards-Subcommittee-of-the-American-Academy-of-Neurology/BLOG/1479655/33379.html rkelley 2009-11-09T21:05:22Z Neurology Modern Medicine Community The various manifestations of what is termed “motor neuron disease” are primarily lower motor neuron involvement, primarily upper motor neuron involvement, primarily progressive bulbar paresis, or most commonly, the combination of upper motor neuron (long tract signs with spastic weakness and hyperreflexia) and lower motor neuron signs (atrophic weakness with fasciculations) often referred to as amyotrophic lateral sclerosis (ALS). The involvement of the bulbar musculature heralds a worse prognosis in terms of swallowing and speech difficulty as well as respiratory involvement. The diagnosis must be established with as much certainty as possible and involves not only a detailed history and thorough neurologic exam but also an electomyogram with nerve conduction velocities. This neurophysiologic study is vitally important and often requires considerable expertise. If there’s any question about the diagnosis, refer to a center with particular expertise in motor neuron disease because the implications of the diagnosis include death, often within several years from onset. However, this can very much depend on the manifestations and the level of supportive care warranted and requested. It is very important not to “give up” on the patient; monitoring the neurologic condition over time can provide considerable emotional support for both the patient and the family. The recent evidence-based review from the American Academy of Neurology (AAN) recommends considering riluzole to slow the disease progression, percutaneous endoscopic gastrostomy (PEG) to stabilize the patient’s weight and to prolong survival, and noninvasive ventilation (NIV) to treat respiratory insufficiency in an effort to prolong survival.1 In an accompanying article, the authors recommend referral to a multidisciplinary clinic should also be considered to improve the quality of life and to ensure that an extra effort is being made to address what can be considerable management needs. Refractory sialorrhea may respond to boxulinum toxin B or low-dose radiation to the salivary glands. Dextromethorphan and quinidine may prove helpful for pseudobulbar affect if approved by the FDA. The authors point out that the excessive fatigue which can be associated with use of riluzole, if counterproductive for the patient, should lead to consideration of its discontinuation. The authors also point out the importance of monitoring for cognitive and behavioral manifestations, including dementia. Despite the limited therapeutic options presently available for ALS, supportive measures and patients’ access to them must be kept in mind for this often devastating neurologic disorder.2 References 1. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Drug, nutritional, and respiratory therapies (an evidence-based review). Neurology. 2009;73:1218-1226.2. Miller RG, Jackson CE, Kasarskis EJ, et al. Practice Parameter update: The care of the patient with amyotrophic lateral sclerosis: Multidisciplinary care, symptom management, and cognitive/behavioral impairment (an evidence-based review). Neurology. 2009;73:1227-1233. als, amyotrophic lateral sclerosis, lou gehrig's disease, neurology nonadult false Amyotrophic Lateral Sclerosis: Update from the Quality Standards Subcommittee of the American Academy of Neurology text blog als,amyotrophic lateral sclerosis,lou gehrig's disease,neurology 268 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771761&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1413325_33379_2771761_ap_160X120.jpg false 0 0 1479655 2771761 Member 0 http://community.modernmedicine.com/_Update-On-Bells-Palsy/BLOG/866980/33379.html In a recent meta-analysis [abstract] of Bell’s palsy treatment, the authors review the available literature on treatment studies of this disorder through March 1, 2009.1 In this exhaustive review of the world’s literature, they provide some evidence-based information for the treatment of Bell’s palsy with specific reference to corticosteroids and antiviral agents. They cite an annual incidence of Bell’s palsy of 20 to 30 per 100,000. This means that practitioners encounter this cranial nerve disorder not infrequently. Mention is also made of the 71% of untreated patients who recover completely, and 84% who will have complete or near-complete recovery. However, for those who do not have a good recovery, there can be very upsetting facial disfigurement from the associated facial droop as well as aberrant facial nerve regeneration which can lead to synkinesis. The synkinesis can manifest as pulling of the perioral musculature on the affected side, with periorbital muscle movement and vice versa. Such cosmetic sequelae should be avoided at all costs as there can be a severe emotional and social impact. Therefore, health care practitioners need to be aware of how best to promote good recovery. This article reports that the number of patients needed to treat with corticosteroids to promote a good recovery in 1 patient was 11. The number needed to treat with corticosteroids to avoid synkinesis and autonomic dysfunction in 1 patient was 7. Antiviral agents alone were not associated with improved recovery. However, the combination of antiviral agents with corticosteroids resulted in improved outcome of borderline significance (P = .05). Their findings included a greater benefit with higher dose corticosteroid treatment, but this appears to have been reflective, at least in part, on the more compelling numbers from larger dose studies. It has been reported that the greatest benefit with corticosteroids is seen in patients who are treated within 72 h of onset. These authors reported no difference in the effect of corticosteroids on unsatisfactory recovery between those treated within 72 h and those treated later on. However, they acknowledged that the subgroup analysis of this observation is “weak.” They also reported that patients presenting with severe involvement of the facial nerve tended to have less of a chance of good recovery with corticosteroid treatment than those with mild-to-moderate facial nerve deficit. Despite the limitations of such meta-analyses, including, as these authors cite in their Discussion, the heterogeneity of outcome measures, this information does support corticosteroid use in Bell’s palsy with possible benefit when given in combination with an antiviral agent such as acyclovir or valacyclovir. Reference1. de Almeida, JR, Al Khabori, M, Guyatt, GH, et al. Combined corticosteroid and antiviral treatment for Bell palsy: A systematic review and meta-analysis. [Clinician’s Corner] JAMA. 2009;302(9):985-993. In a recent meta-analysis [abstract] of Bell’s palsy treatment, the authors review the available literature on treatment studies of this disorder through March 1, 2009.1 In this exhaustive review of the world’s literature, they provide some evidence-based information for the treatment of Bell’s palsy with specific reference to corticosteroids and antiviral agents. They cite an annual incidence of Bell’s palsy of 20 to 30 per 100,000. This means that practitioners encounter this cranial nerve disorder not infrequently. Mention is also made of the 71% of untreated patients who recover completely, and 84% who will have complete or near-complete recovery. However, for those who do not have a good recovery, there can be very upsetting facial disfigurement from the associated facial droop as well as aberrant facial nerve regeneration which can lead to synkinesis. The synkinesis can manifest as pulling of the perioral musculature on the affected side, with periorbital muscle movement and vice versa. Such cosmetic sequelae should be avoided at all costs as there can be a severe emotional and social impact. Therefore, health care practitioners need to be aware of how best to promote good recovery. This article reports that the number of patients needed to treat with corticosteroids to promote a good recovery in 1 patient was 11. The number needed to treat with corticosteroids to avoid synkinesis and autonomic dysfunction in 1 patient was 7. Antiviral agents alone were not associated with improved recovery. However, the combination of antiviral agents with corticosteroids resulted in improved outcome of borderline significance (P = .05). Their findings included a greater benefit with higher dose corticosteroid treatment, but this appears to have been reflective, at least in part, on the more compelling numbers from larger dose studies. It has been reported that the greatest benefit with corticosteroids is seen in patients who are treated within 72 h of onset. These authors reported no difference in the effect of corticosteroids on unsatisfactory recovery between those treated within 72 h and those treated later on. However, they acknowledged that the subgroup analysis of this observation is “weak.” They also reported that patients presenting with severe involvement of the facial nerve tended to have less of a chance of good recovery with corticosteroid treatment than those with mild-to-moderate facial nerve deficit. Despite the limitations of such meta-analyses, including, as these authors cite in their Discussion, the heterogeneity of outcome measures, this information does support corticosteroid use in Bell’s palsy with possible benefit when given in combination with an antiviral agent such as acyclovir or valacyclovir. Reference1. de Almeida, JR, Al Khabori, M, Guyatt, GH, et al. Combined corticosteroid and antiviral treatment for Bell palsy: A systematic review and meta-analysis. [Clinician’s Corner] JAMA. 2009;302(9):985-993. Tue, 29 Sep 2009 15:04:20 GMT http://community.modernmedicine.com/_Update-On-Bells-Palsy/BLOG/866980/33379.html rkelley 2009-09-29T15:04:20Z Neurology Modern Medicine Community In a recent meta-analysis [abstract] of Bell’s palsy treatment, the authors review the available literature on treatment studies of this disorder through March 1, 2009.1 In this exhaustive review of the world’s literature, they provide some evidence-based information for the treatment of Bell’s palsy with specific reference to corticosteroids and antiviral agents. They cite an annual incidence of Bell’s palsy of 20 to 30 per 100,000. This means that practitioners encounter this cranial nerve disorder not infrequently. Mention is also made of the 71% of untreated patients who recover completely, and 84% who will have complete or near-complete recovery. However, for those who do not have a good recovery, there can be very upsetting facial disfigurement from the associated facial droop as well as aberrant facial nerve regeneration which can lead to synkinesis. The synkinesis can manifest as pulling of the perioral musculature on the affected side, with periorbital muscle movement and vice versa. Such cosmetic sequelae should be avoided at all costs as there can be a severe emotional and social impact. Therefore, health care practitioners need to be aware of how best to promote good recovery. This article reports that the number of patients needed to treat with corticosteroids to promote a good recovery in 1 patient was 11. The number needed to treat with corticosteroids to avoid synkinesis and autonomic dysfunction in 1 patient was 7. Antiviral agents alone were not associated with improved recovery. However, the combination of antiviral agents with corticosteroids resulted in improved outcome of borderline significance (P = .05). Their findings included a greater benefit with higher dose corticosteroid treatment, but this appears to have been reflective, at least in part, on the more compelling numbers from larger dose studies. It has been reported that the greatest benefit with corticosteroids is seen in patients who are treated within 72 h of onset. These authors reported no difference in the effect of corticosteroids on unsatisfactory recovery between those treated within 72 h and those treated later on. However, they acknowledged that the subgroup analysis of this observation is “weak.” They also reported that patients presenting with severe involvement of the facial nerve tended to have less of a chance of good recovery with corticosteroid treatment than those with mild-to-moderate facial nerve deficit. Despite the limitations of such meta-analyses, including, as these authors cite in their Discussion, the heterogeneity of outcome measures, this information does support corticosteroid use in Bell’s palsy with possible benefit when given in combination with an antiviral agent such as acyclovir or valacyclovir. Reference1. de Almeida, JR, Al Khabori, M, Guyatt, GH, et al. Combined corticosteroid and antiviral treatment for Bell palsy: A systematic review and meta-analysis. [Clinician’s Corner] JAMA. 2009;302(9):985-993. antivirals, bells palsy, neurology nonadult false Update On Bell's Palsy text blog antivirals,bells palsy,neurology 184 0 0.0 http://community.modernmedicine.com/service/displayKickPlace.kickAction?u=2771761&as=33379 http://media.kickstatic.com/kickapps/images/33379/photos/PHOTO_1413325_33379_2771761_ap_160X120.jpg false 0 0 866980 2771761 Member 0